NYS EMTs

[Jaideux]

Hi

I do hope I'm in the right spot. I didn't see anything quite about this in my search. If I missed something, I'm happy to check out an old link!

In New York, what are the rules about taking a patient to a different hospital than the one requested? When is it okay, if ever?

Here is the situation: I'm volunteer EMT, but my real job is working at a regional trauma center, which is also home to the largest psychiatric in-patient care in the area. I work in emergency psych. So, I'm torn between the sides.

Here it is:

My coworkers really have a problem with all the city medics bringing psych patients to us when we are code red (very acute). Unfortunately, in this city, it seems like most of our hospitals are red most days I frequently try to point out that even though we are operating at max (an above) capacity, the other hospitals which do psych are also probably in a similar boat. When everyone is red, it really means everyone is green, haha.

It seems our charge nurses have gotten in the habit of calling the company that has the city contract (and the other commercial company) and telling/asking their dispatchers to direct crews to no longer bring us patients. Here's where I get torn and really would like some education, for my self, and that I can pass on:

From the psych side:

We are a locked unit. People cannot sign out AMA until cleared by a psychiatrist and when we're busy, it's not uncommon to have 10 hour waits from start to finish. This creates significant tension. Tension can lead to violence, requiring restraints, requiring someone to sit and do a 1-to-1 with the patient, reducing the number of available staff to get people seen and discharged or admitted. To keep it fair, we have a policy to see people in the order they arrive. Even if there were no distractions, no other patients, it would still be at least an hour process. That never happens, and we have to get collateral, wait for labs, wait for them to sober up before we can even interview, so there is usually some sort of backup.

There are 3 other hospitals in this city that can accomodate emergency psych issues, and I'm pretty sure all 3 admit. I know 2 do. We may be the only ones with child/adolescent inpatient units. It feels like a disproportionate number come here (but this is an assumption, on my part).

It really, really sucks to be overworked. It sucks even more to be in a dangerous setting.

Our peds patients are in the same waiting room as the adults, and they are exposed to everything that goes on out there. Granted, they are SUPPOSED to have a parent with them, and there is a sort of wall protrusion separating them, but it's by no means very separate.

From the EMS side:

They are a hospital. It is their job to treat patients, no matter how many show up or in what condition. We are just the proverbial messenger.

If the cops MHA the patient to Hospital X, we have to take them to Hospital X. (Don't we?)

If the patient says, "Take me to Hospital X" we have to take them to Hospital X. (Don't we?)

So, does anyone have any information on whether or not EMTs actually have to transport a patient to a hospital if there is a concern for patient/staff safety based on a violence potential?

As an EMT, I always give my patients the most updated information I have about the hospital codes (Green, Yellow, Red) so they can make an informed choice, but what about the patient that says, "Hospital X" even after I explain it will be a 3+ hour wait to be seen? They all start out thinking they can wait... and after an hour say "I'm leaving", and hospital staff has to say, "no, you're not", and it has been known to get ugly.

What if the patient is typically treated at one hospital, but the cops MHA to a different one, or the pt requests to go to a different one?

Additionally, if anyone has any good strategies how I can bridge the "us v. them" gap that I'm surrounded by and help each side see the other sides viewpoint/limitations/policies/laws, please let me know!!! I'm so sick of hearing nurses bashing us EMTs because we brought in the 5th patient in the last hour, and I'm also sick of EMTs bitching about sometimes long wait between triaging at the main EMS area and us psych people having time to come downstairs and pick them up to go to the separate psych area, or getting pissy when I ask (nicely!!) to try and go to other hospitals because I fear for my safety. And I'm on pretty good terms/friends with nearly all the EMTs with the city, because my boyfriend works there and I hang out with them quite a lot! Trust me, we aren't sitting up here twiddling our thumbs eating bonbons. And the few times we've called the city law enforcement for patients who were terribly violent (and NOT psychotic!), they were completely unhelpful, so I don't feel like they "have my back".

Help? Please? Point me to a policy number, or a lack of policy. Anything.

[brentoli]

I can't answer to NYS laws and regulations.

Honestly, if you want the real true correct answer, go here first before relying on what anyone from here tell you:

Bureau of Emergency Medical Services

Central Office

Hedley Park Place

433 River Street

Suite 303

Troy, NY 12180

(518) 402-0996

(518) 402-0985 Fax

--

What I can tell you, is that EMS takes paitents to their choice of destination, unless the destination can not recvieve them, or the person can not make the choice. In that case the most appropriate reciving facility is where they are taken. I will be honest, I didn't read the whole post because I don't know your system or how it operates. In our county, we have one hospital that is able to accept psych paitents. They have adequate security, adequate accomidations, and an inpaitent center to transfer them to on campus. All of our psych paitents go there. We really don't have to worry about that not being their choice, because most people in that situation, know that center is what they want checked into.

Hopeully you can call someone in that office and get an answer. Also you might be able to get some common sense answers from the community here.

[Jaideux]

Thanks so much for your suggestion! I didn't know the bureau existed... I will be contacting them ASAP!

I'm really glad your community has the adequate resources to treat your patients. Ours is experiencing (like so many others) the "more people using the ED for bullcrap/ PCP stuff" trend, so even though we just opened up many new beds, and have the nursing/MD staff to staff them, we still have many nights a month where we are overwhelmed with people. Confounding the psych factor is that we have a lot of truly unnecessary MHAs brought here. Less than 1/3 of the people we see get admitted. I'm not being bitter or jaded when I say that I truly think the police would rather drop off the drunks at our doorstep than fill out paperwork to incarcerate them after a barfight. "Oh, he hit someone. I know it's an illegal act, but once upon a time he was in an elevator with a psychiatrist, so he must have a mental illness. It's not right to arrest him." Garbage. And lots of kids who say angry teen things to their parents, who have them MHAd. "Dear Mom and Dad: The fact that Junior trashed your house during a fight with you does not make him bipolar. It makes you ineffective parents somewhere along the line."

Not to mention all our "frequent flyers" who use the local EDs like rotating Holiday Inns. They know if they utter the word "chest pain" they are guarenteed at least a few hours in the medical ED while labs are being run, or even sitting in the waiting room. Plus, they know they can get free food, like sandwhiches and ginger ale. And then throwing around the "s" or "v" word (suicide or hearing voices), they know they can buy a few more hours up in psych, watching cable tv and eating MORE free food. And they waste taxpayer money, 9 times out of 10. $500 to take the BLS bus in, and $1500 for the cardiac work up, and another $1500 for the psych evals. And some of them do it at least once a week, if not more! We've known people to call for an ambulance from the waiting room of one ED after discharge to be taken to another! Once, a guy was d/c from one psych hospital, escorted out by the police, and he said "I'm hearing voices" so they MHAd him to us! Even though he was just cleared 10 minutes prior!!

/rant that is becoming less about my original post.

I'm just frustrated

[nypamedic43]

I too am unsure about the system where you are. In the city that I work in, we have 2 hospitals. One doesnt do psych at all and the other has 2 psych beds in the ED and a BSU on the second floor.

The psych patients that we come into contact with go to the second hospital, they are equipped to handle them. MOST of the time (but not all) the police are involved and the patient is a voluntary. This buys them 72 hours of observation either in the ED or they get admitted to the BSU. However, if the floor is at capacity and the ED cannot provide the correct care, they ship them out to another facility. Most of the time this in NOT voluntary, which requires a 2PC. 2 physicians signatures to say that they are not capable of making safe decisions.

The thing that bothers me about your post is this....the state of NY frowns heavily on charge nurses putting a hospital on diversion for a specific type of patient. That decision has to come from the hospital administrators NOT the nurses that are working the specific areas of the hospital. They need to be very careful doing this. We had a nurse fired because she decided that the ED had taken enough patients for the night and put the WHOLE hospital on diversion. The hospital paid heavy fines and she got fired....immediately.

From the EMS side...we have no control over the calls that are brought in the ED. It isnt EMS's fault if there is a whole slew of chest pain calls, or respiratory calls or psych calls. Unless it is in the best interests of the patient to go to a specific hospital ie: stroke center, chest pain center, BSU, they are taken to the hospital of choice otherwise, if they are lucid enough, they can sue for false imprisonment, kidnapping and the list goes on. My service transports psych patients over the PA state line...if the patient realizes it and they are a voluntary intake for psych, they can MAKE us stop and let them out of the ambulance and we have no recourse but to comply with their wishes.

I can see that you are kind of stuck in the middle and being able to see both sides can put you in that sticky situation. I hope you find the answers that you are searching for.

[fiznat]

Although I'm not familiar with the laws in NY, I can say that here in CT the mechanism for dealing with overloaded departments is hospital diversion. Hospitals around here frequently go on diversion for specific types of patients, usually psych or trauma. What that means to us EMS workers is that we should take patients of these types to a different facility (a pre-arranged "accepting hospital") as long as they are stable and otherwise could stand a few more minutes in the ambulance.

I understand hospitals don't like to go on diversion, but if this is as much as a safety issue as you are saying, then you do what you have to do. This halfway method of requesting EMS agencies under the table to transport somewhere else is kinda BS, because then you put the responsibility of changing requested destinations on the prehospital people, which isn't right and isn't fair. If a hospital tells me they are full but refuses to go on diversion I may mention to the patient there there will be a long wait, but I will absolutely not refuse to transport to that facility. If a hospital is so overloaded that it can't handle another patient: it needs to go on diversion. Otherwise, suck it up. (IMHO)

Edited March 21, 2009 by fiznat

[EMS Solutions]

NYC has a ten minute rule. Meaning that you can bring a patient to their hospital of choice as long as that hospital is not longer than 10 minutes away from the closest hospital.

With that said, special patient types psych, trauma, burns etc. are transportated to the appropriate facility unless certain criteria are met such as unmanageable airway or cardiac arrest- then they go to the closest.

When a hospital Er is on diversion and a patient requests transport to that hospital, patients are advised to choose a another hospital. But if the patient insists on that hospital anyway, and it meets the 10 minute rule, then you take them where they want to go.

Two other points - If a patient is a psych patient and the ER is on diversion, you would take them to the next available appropriate facility. If both are on a diversion status, then they go to the closest.

lastly - if a patient requests transport to a hospital longer than the 10 minute rule or you feel that even the 10 minute rule may compromise the patient. Then contact with medical control for approval is required. Mostly they will approve transport to the patients requested ER.

Now I dont think I covered all the bases, but this is the basics of it.

[HERBIE1]

From the EMS side, it seems to me transports are simply a system policy issue. In our city, we try to accommodate a patient's hospital request- within reason. Obviously patient condition, time difference between closest and desired locations, capabilities of the receiving hospital, diversion status, time of day(traffic), call volume, and more- are all considerations. There are established guidelines that deal with taking OB or pediatric patients to capable facilities, trauma patients to trauma centers, but in general a comprehensive ER should be able to handle anything- at least in the short term. Now, with the advent of specialized stroke centers and cardiac centers to handle MI's, the problem is only compounded and although a stroke center is best for a patient having those symptoms, it can leave a void in your coverage area when you are gone.

There are pro's and cons of trying to honor a request, and as far as the police is concerned, often times they prefer a patient be brought to a closer hospital, in or near their assigned district- especially if there are multiple victims and may need to take statements and make reports from everyone involved. When a rig takes a patient far from their assigned area, in a busy system, it has a snowball effect which causes vacancies in areas, response times increase, and things can quickly get out of hand. Obviously when hospitals are so full they can no longer accept ambulance patients, these extended transports cannot be helped, but any efforts to "please" the patient, their doctor, or law enforcement must be tempered with common sense. In these cases, the impact on the entire system has to be taken into account.

These days, patients are considered customers and it's all about customer service in both the prehospital and hospital settings. Clearly there are many factors involved here and I think the more you know about your system, it's capabilities, and shortcomings, the better you will be able to make the best decision for your patient and for the rest of the system. You need to seriously consider the consequences of any transport decisions and how they impact everyone around you.

Also, the amount of latitude a system gives it's crews to make these decisions varies quite a bit from city to city.

[djmedic]

I worked in Buffalo, NY for over 4 years before moving away...

The main rule is if the pt is CAOx3 then you take them where they wanna within distance limits...otherwise it is kidnapping

exceptions: critical non-CAO x3 calls are closest most appropriate facility (meaning trauma goes to the level trauma center bypassing as many hospitals as needed to get there. There is still a judgement that goes with this for closest facility for quick stabilization [for distance reasons])

We had a stroke center in Buffalo and if our Pt or family was requesting a different hospital we would strongly recommend the most appropriate but ultimately had to go where told.

For Psych: we had to locked Psych ER's in the city and pshych Pt's (ie. suicidal, halucinations, schizophrenics, etc.) would get a choice of either hospital with psych ER...

So sorry about that but if a particular hospital specializes in something (ie. Cardiac Center, Stroke Center, Level I trauma center, or Psych) they will tend to get more than they can handle or want...

[HERBIE1]

I worked in Buffalo, NY for over 4 years before moving away...

The main rule is if the pt is CAOx3 then you take them where they wanna within distance limits...otherwise it is kidnapping

exceptions: critical non-CAO x3 calls are closest most appropriate facility (meaning trauma goes to the level trauma center bypassing as many hospitals as needed to get there. There is still a judgement that goes with this for closest facility for quick stabilization [for distance reasons])

We had a stroke center in Buffalo and if our Pt or family was requesting a different hospital we would strongly recommend the most appropriate but ultimately had to go where told.

For Psych: we had to locked Psych ER's in the city and pshych Pt's (ie. suicidal, halucinations, schizophrenics, etc.) would get a choice of either hospital with psych ER...

So sorry about that but if a particular hospital specializes in something (ie. Cardiac Center, Stroke Center, Level I trauma center, or Psych) they will tend to get more than they can handle or want...

You are right about specialty centers. These days, in order to get the best outcome for your patient, clearly the best option is to take them where they will receive the most appropriate care. The only exception we have is for burn patients. We have a couple burn centers, but a serious burn is not a reason to head to a burn center- especially if there are airway issues. Let the nearest comprehensive ER take them, stabilize the airway- secure the airway with a trach, fasciotomy, central lines for fluid etc, and let them transfer the patient later.

Want to scare the crap out of an ER- take them an OB patient- especially high risk if they have no peds or OB facilities. Their lawyers only see potential lawsuits and want no part of them.

Like you said, many times these specialty centers get more than they bargained for. When the trauma system was first established, rules regarding what constituted a trauma patient were pretty liberal. As a result, they were flooded because nearly any injury qualified as a "trauma". The system was tweaked and essentially triaged the trauma patients based on mechanism of injury, stability, airway issues, etc but in today's world, there is plenty severe trauma to go around. Then again, just like us, in order to become top notch, they need the practice. LOL

[Chief1C]

http://www.health.state.ny.us/nysdoh/ems/main.htm